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Our objective was to investigate an epidemic of gonorrhoea among homosexually-active men in Sydney. Demographic and behavioural data on all homosexually-active men diagnosed with gonorrhoea (any site) at the Sydney Sexual Health Centre (SSHC) from 1992 through 1998 were reviewed. The men diagnosed with anal gonorrhoea were then compared with all homosexually-active men who tested negative for anal gonorrhoea or who were not tested for anal gonorrhoea at the SSHC between 1996 and 1998. Data on HIV status and country of birth of men diagnosed with anal gonorrhoea during 1998 at the Taylor Square Private Clinic were also reviewed. Over the period 1992 to 1998, homosexually-active men diagnosed with gonorrhoea at SSHC tended to become older at the time of diagnosis (median age 26.5 years in 1992 up to 31.0 years in 1998), indicating a cohort effect in the clinic population due to service reductions. When compared with men who tested negative for anal gonorrhoea at SSHC between 1996 and 1998, those with anal gonorrhoea were more likely to have anogenital symptoms (adjusted odds ratio [OR] 2.3), to have had a past history of gonorrhoea (OR 3.1), to present as a contact of gonorrhoea (OR 8.6), to have used condoms less consistently (OR 2.3), to be HIV positive or of unknown HIV status (OR 3.2), and to have been born in an English-speaking country other than Australia (OR 2.9). The last feature was not observed at the private clinic. In conclusion, the gonorrhoea epidemic was linked to public health service reductions, though it seems unlikely to be the only factor. Homosexually-active men with anal gonorrhoea had well established behavioural risk factors while men with concurrent HIV infection were over-represented. Given the role of gonorrhoea in promoting the spread of HIV infection, a National Sexual Health Strategy--closely linked to the National HIV/AIDS Strategy--is due. [ABSTRACT FROM AUTHOR]

Factors affecting the response to hepatitis B vaccination in a primary care setting were examined by means of a review of case notes of patients attending 22 sexually transmissible disease services. Where not available from the notes, presence of antibody to hepatitis B surface antigen (anti-HBs) was determined by testing available stored serum. One hundred and ninety-five patients completed a course of 3 injections and had an anti-HBs assay performed. The highest response rate (anti-HBs > or = 10 IU/L) was found in human immunodeficiency virus (HIV)-negative heterosexual women (16 of 17, 94.1%) followed by HIV-negative heterosexual men (11 of 12, 91.7%); HIV-negative homosexual men (105 of 120, 87.5%); and HIV-positive homosexual men (6 of 14, 42.9%). (For HIV-positive vs HIV-negative homosexual men, P = 0.0003). Eleven of 14 (78.6%) homosexual men of unknown HIV status responded to vaccination. There was a trend to lower CD4+ lymphocyte counts among HIV-infected patients who responded to hepatitis B vaccination (mean 482 cells/cm2) when compared to those that did not respond (632 cells) but this difference was not statistically significant (P = 0.330). Neither the type of vaccine (recombinant, plasma-derived or mixed) nor the length of vaccination course (mean 6.2 months; range 2 to 18) affected response. This study confirmed that vaccination against hepatitis B is much less effective in HIV-infected homosexual men and marginally less effective for HIV-negative homosexual men, though the mechanism for this reduced response is uncertain. Reassuringly vaccine response was not affected by common variables in primary care settings such as vaccine type or delays in the vaccine schedule. [ABSTRACT FROM AUTHOR]

Gynaecomastia has been reported in an HIV-1- infected man treated with a triple antiviral regimen including indinavir1. We describe 4 cases of men with gynaecomastia associated with saquinavir (hard gel capsule) therapy who denied taking any hormonal supplements or opiates. [ABSTRACT FROM AUTHOR]

Objective: This randomized, double-blind and vehicle-controlled phase III study was conducted to evaluate the efficacy and safety of alitretinoin gel 0.1% for the topical treatment of the cutaneous lesions of AIDS-related Kaposi's sarcoma (KS)., Methods: Patients received treatment with alitretinoin gel (n = 62) or vehicle gel (n = 72) twice daily for 12 weeks. The primary efficacy endpoint was the cutaneous KS tumor response rate according to AIDS Clinical Trials Group (ACTG) objective criteria applied to topical therapy, with the patient as the unit of analysis., Results: Treatment of patients with alitretinoin gel resulted in a significant antitumor effect. The overall patient response rate (complete plus partial response) was 37% (23 of 62) for the alitretinoin-treated patients and 7% (5 of 72) for the vehicle-treated patients (p = 0.00003). The difference in response rates for the 2 treatment groups remained significant even after taking into consideration numerous variables, including age (p = 0.00001), Eastern Cooperative Oncology Group (ECOG) status (p = 0.00002), CD4+ cell count (p = 0.00002), history of opportunistic infection (p = 0.00002), aggregate area of indicator lesions (p = 0.00005), number of raised indicator lesions (p = 0.00002), prior therapy for KS (p = 0.00003), and number of drugs (p = 0.00002) used in concomitant antiretroviral therapy. Generally, treatment with alitretinoin gel was well tolerated. The overall incidence of adverse events was similar for the 2 treatment groups. Adverse events related to treatment with alitretinoin gel tended to be mild to moderate in severity and limited to the site of application. The most frequent adverse event occurring at the application site following alitretinoin gel treatment was irritation coded as rash (32%)., Conclusions: The results of this study provide convincing evidence of the superiority of alitretinoin gel over vehicle gel for the treatment of the cutaneous lesions of AIDS-related KS.

Guidelines for universal blood and body fluid precautions (UBBFP) designed to protect health care workers from occupational exposure to blood borne pathogens have been developed by the US Centers for Disease Control. These guidelines have been adopted by the New South Wales Department of Health and all major Australian hospitals. To determine the degree of understanding and utilization of UBBFP by Australian nurses, 192 nurses were asked about UBBFP, recent occupational exposures and understanding of hepatitis B transmission. Seventy-three per cent of nurses stated they 'used UBBFP at all times', yet only 58% of these nurses stated they always used gloves when 'handling blood or blood equipment' and just 85% reported always using 'gloves to clean up urine and faeces'. Overall 146 (76%) nurses experienced 230 occupational exposures (168 mucocutaneous, 48 percutaneous) in the previous 6 months. These were more common in men (P=0.024) and in operating theatres (95% of nurses) and high dependency units (88%). Percutaneous exposures were significantly more frequent in nurses who stated they did not wear gloves when handling blood/blood equipment (P=0.036), whereas mucocutaneous exposures were significantly more frequent among nurses who stated they do not adhere to UBBFP at all times (P=0.005). Eighty-three per cent of nurses experiencing exposures did not report all of them. In this study knowledge and adoption of UBBFP translated directly into lower risk for an occupational exposure. It is concluded that educational strategies to improve understanding and adoption of UBBFP by nurses are required.

The purpose of this study was to estimate the incidence of human immunodeficiency virus (HIV) in a cohort of homosexually active men in Sydney. In 1984-85 the Sydney AIDS Prospective Study enrolled homosexually active men, who were followed by six-monthly visits, although regular contact with most participants ceased in the early 1990s. In 1993-94 a major effort was made to establish the HIV status of all participants who had attended more than once. Of the 1075 men enrolled, 528 (49 per cent) were negative at enrollment and had at least one further documented HIV test. The annual incidence rate of HIV infection was highest in the early years of the study, 1984 (9.6 per cent) and 1986 (5.0 per cent), and remained low from 1987 (1.9 per cent) to 1994 (0.0 per cent). The incidence of HIV infection was higher among men aged under 34 years at enrollment and men who reported more than four sexual partners in the six months before enrollment, but these associations disappeared by 1987. The decrease in HIV incidence is consistent with findings from other cohorts followed for this length of time.

The influence of human immunodeficiency virus (HIV) infection and vaccination schedule on the immunogenicity of a hepatitis A vaccine was examined. Ninety HIV-infected homosexual men received two vaccinations with hepatitis A vaccine (each 2 mL of 720 ELISA units/mL) either 1 or 6 months apart; 44 HIV-uninfected men received vaccine at study entry and at 6 months. Anti-hepatitis A virus (HAV) titer after vaccination was measured in 83 HIV-positive and 39 HIV-negative men. Seroconversion (anti-HAV antibody > or = 20 IU/L) after two vaccinations occurred more frequently in HIV-negative men (100% vs. 88.2%; P = .03). Anti-HAV titer after two vaccinations was also significantly greater in HIV-negative men (1086 vs. 101 IU/L; P = .0001). HIV-positive men who responded to vaccination had significantly more CD4 lymphocytes (mean, 540/microL) at baseline than those who did not (280/microL; P = .033). Vaccine schedule did not affect response. Vaccination of susceptible patients against HAV should be recommended early in HIV infection using the shorter course to encourage compliance.

Objective: To determine the long-term safety of inactivated hepatitis A virus (HAV) vaccine in men infected with HIV-1., Design: A 1-year prospective case-control study., Setting: Targeted primary care and sexually transmitted diseases clinics., Patients: Ninety HIV-1-positive patients who participated in an earlier efficacy study of HAV vaccination., Controls: Ninety HIV-1-positive men, matched for CD4+ lymphocyte percentage at baseline, who did not receive HAV vaccine., Intervention: All cases were assigned to receive two intramuscular doses of 1440 enzyme-linked immunosorbent assay units of inactivated HAV vaccine (Havrix) either 1 or 6 months apart., Main Outcome Measures: Development of AIDS, survival, and T-cell subsets after 1 year of follow-up., Results: No significant differences were seen between cases and control for the development of AIDS (10.1 versus 10.7%), deaths (7.3 versus 7.6%) nor for mean decline in circulating CD4+ lymphocyte count (125 versus 123 x 10(6)/1) after 1 year., Conclusions: Vaccination against HAV appears to be safe in the longer term for HIV-1-infected men.

The purpose of this study was to determine the magnitude of the difference in patient preference/utility for intravenous (i.v.) ganciclovir compared with oral ganciclovir for maintenance treatment of cytomegalovirus (CMV) retinitis. We used a cross-sectional, interviewer-administered time trade-off (TTO) exercise with hypothetical health state descriptions, based upon data from clinical trials and the published literature. The study was conducted in a private clinic in Sydney Australia, specialising in the care of people with HIV. A total of 80 individuals with HIV infection who had not developed AIDS were administered the TTO instrument. The main outcome measure was the difference between each respondent's utility score for oral and i.v. ganciclovir maintenance therapy. When the 80 HIV-positive patients were presented with information on drug efficacy, adverse effects and mode of administration, 60 (75%) preferred oral ganciclovir, 4 patients preferred i.v. ganciclovir, and 16 were indifferent. The median utilities were 0.837 (oral ganciclovir) and 0.475 (i.v. ganciclovir). The difference in rankings was statistically significant by Wilcoxon's signed-ranks test (Z = -6.69, p < 0.00005). The median utility scores suggest that, all other things being equal, individuals with HIV infection would prefer an oral formulation of ganciclovir to i.v. administration in the event of CMV retinitis infection.

Objective: To evaluate the safety and efficacy of the anabolic steroid, nandrolone decanoate (Deca Durabolin) in patients with HIV wasting who are resistant to nutritional intervention., Design: A 16-week open trial with subjects who had lost 5-15% of their usual body weight., Setting: HIV/AIDS specialist ambulatory care services, both public and private, in sydney, Australia., Participants: Two hundred and twenty men entered the pre-therapy phase, and of these, 24 failed to gain weight and were enrolled. Seventeen subjects (81%) completed the 16-week trial., Interventions: Pre-therapy nutritional assessment and education was conducted by the clinical dietitian. Those who failed to gain weight (10.9%) were treated with nandrolone decanoate (100 mg/ml) by deep intramuscular injection every 2 weeks for 16 weeks., Main Outcome Measures: Changes in weight and body composition (lean body mass, total body water and nitrogen index) were measured by anthropometry, bioelectrical impedance, and in vivo neutron activation. Changes in quality of life were assessed by the 30-item Medical Outcomes Study short form questionnaire. Changes in biochemistry, haematology and immunology were also measured., Results: There were significant increases in weight (mean, 0.14 kg per week; P < 0.05) and lean body mass (mean, 3 kg by anthropometry; P < 0.005). The change in lean body mass was of similar magnitude across all measurement modalities. Quality of life parameters, especially functionality, increased significantly during the trial. No subject experienced toxicity., Conclusion: Nandrolone decanoate has beneficial effects on weight, lean body mass and quality of life in selected patients who have mild to moderate HIV wasting.

Objectives: To determine the change in prevalence of hepatitis B virus infection among "at risk" patients attending the Sydney Sexual Health Centre between 1982 and 1991 and to determine the hepatitis B vaccination status of the 1991 group., Study Population: Consecutive patients attending the Centre between 1 July and 31 December 1991 who belonged to at least one of the following risk groups: men who have sex with men (n = 351); female prostitutes (n = 124); and injecting drug users (n = 153)., Design: Hepatitis B infection status was assessed on the basis of patient history and blood testing. All patients without a history of hepatitis B infection or vaccination were offered screening for serum markers of hepatitis B infection. Hepatitis B infection status was correlated with age, sex, country of birth, sexual behaviour and injecting drug use and was analysed separately according to risk category., Results: The prevalences of any hepatitis B marker were: men who have sex with men 38.2% (61.0% in 1982; P < 0.0001); local female prostitutes 14.1% (28.8% in 1982; P = 0.024); international female prostitutes 58.4%; and injecting drug users 42.0%. Of those in the 1991 sample without a history of hepatitis B infection, 27.6% of men who have sex with men, 27.9% of local female prostitutes, 18.2% of international female prostitutes and 7.1% of injecting drug users were vaccinated., Conclusions: The significantly lower prevalences of serum markers of hepatitis B infection among men who have sex with men and local female prostitutes when compared with 1982 suggest widespread adoption of safer sexual practices. The high prevalence of chronic hepatitis B infection among international female prostitutes indicates a potentially significant source of sexually transmitted hepatitis B infection in Sydney. The low vaccination rates provide an argument for mass vaccination against hepatitis B.

Objective: To identify risk factors, particularly circumcision status, associated with serological evidence of herpes simplex virus type 2 (HSV-2) infection of heterosexual men., Design: A cross-sectional case-control study employing an anonymous delinked interviewer-administered questionnaire, clinical examination, and a type-specific serological test for HSV-2., Participants and Setting: Three hundred consecutive heterosexual male patients at a public sexually transmissible diseases (STD) clinic in Sydney, Australia., Main Outcome Measures: Associations between serological evidence of HSV-2 infection and history of genital herpes or contact with genital herpes, history of other common STDs, and demographic and behavioural factors such as age, education level, number of sexual partners and lack of circumcision., Results: One hundred and ninety-four patients (64.7%) had antibodies to HSV-2 but only 24% of these gave a history of genital herpes. A history of genital herpes or sexual contact with genital herpes, reported total lifetime number of sexual partners, failure to complete high school and a history of non-gonococcal urethritis or genital warts were associated with serological evidence of HSV-2 infection at the univariate level. Neither increasing age nor lack of circumcision was associated with HSV-2 infection. Following multivariate analysis only the lifetime number of partners and failure to finish high school were significantly strong predictors of HSV-2 infection., Conclusion: This is the highest prevalence of HSV-2 infection ever detected in an Australian population and one of the highest recorded globally. As younger men were as commonly infected as older men, and an earlier (1985) study involving the same clinic yielded a lower prevalence, it appears that a high level of ongoing HSV-2 transmission is occurring among Sydney heterosexuals. Increased awareness of this fact could enhance safer sex campaigns.

The entire structural gene of the Clostridium botulinum NCTC 11219 type-E neurotoxin (BoNT/E) has been cloned as five overlapping DNA fragments, generated by polymerase chain reaction (PCR). Analysis of triplicate clones of each fragment, derived from three independent PCR, has allowed the derivation of the entire nucleotide sequence of the BoNT/E gene. Translation of the sequence has shown BoNT/E to consist of 1252 amino acids and, as such, represents the smallest BoNT characterised to date. The light chain of the toxin exhibits the highest level of sequence similarity to tetanus toxin (TeTx, 40%). The light chains of BoNT/A and BoNT/D share 33% similarity with BoNT/E, while BoNT/C exhibits 32% similarity. In contrast, the TeTx heavy chain exhibits the lowest degree of similarity (35%) with BoNT/E, with the BoNT heavy chains sharing 46%, 36% and 37%, for neurotoxin types A, C and D, respectively. Comparisons with partial amino acid sequences of the light chain of BoNT/E from C. botulinum strain Beluga and that from the strains Mashike, Iwanai and Otaru, indicate single amino acid differences in each case. Alignment of all characterised neurotoxin sequences (BoNT/A, BoNT/C, BoNT/D, BoNT/E and TeTx) shows them to be composed of highly conserved amino acid domains interspersed with amino acid tracts exhibiting little overall similarity. The most divergent region corresponds to the extreme COOH-terminus of each toxin, which may reflect differences in specificity of binding to neurone acceptor sites.